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What should we consider when anaesthetising patients, including geriatrics, for dental procedures?

What should we consider when anaesthetising patients, including geriatrics, for dental procedures?

Dentistry has become an important part of everyday veterinary practice. In addition to a routine dental caseload, the relationship between increasing age and the progression of dental and periodontal disease means that geriatric patients are often in need of dental assessment and/or treatment. It is well recognised that geriatric patients have a higher incidence of concurrent disease which, alongside other age-related changes, can complicate the anaesthetic approach and contribute towards an increased risk of anaesthetic complications. Despite this, by using modern anaesthetic procedures (including appropriate monitoring and support), in general-terms the benefits of dental therapy in this population far outweigh the risks. The following article will discuss some of the measures that can be taken when faced with patients that require dental therapy to be performed under general anaesthesia with additional considerations made for geriatric patients.

Please also read our previous articles on ‘Pain, what a Pain! (Part 2)’ for practical tips on how to perform dental nerve blocks in companion animal practice, ‘What should we consider when anaesthetising the geriatric patient?’ and 'Practical Acute Pain Assessment' both by Carl Bradbrook, for a more thorough breakdown of anaesthetic and analgesic considerations in this specific patient population.


Many of the procedural considerations outlined below are relevant for any patient undergoing dental therapy and so should be considered responsible steps whatever the patients signalment and presentation.

Pre-anaesthetic assessment

Thorough pre-anaesthetic assessment should take place in every patient undergoing any form of anaesthesia and the anaesthetic approach adjusted as necessary. This is of particular importance in those of advanced age given the range of co-morbidities associated with this patient group.

Preoperative blood testing should take place in line with patient history, clinical examination, perioperative risk assessment, clinical judgement and practice policy (Robertson et al. 2018). Based on the findings of Joubert (2007) pre-anaesthetic blood screening of canine patients over the age of 7 is recommended as 30-50% of animals in this age group have some degree of subclinical disease. A retrospective study of preanaesthetic blood screening in cats of an average age of 11.6 years identified that almost 16% had abnormal results documented as a matter of concern, and in almost 1% it identified problems that were not recognised from the history or clinical examination (Davies and Kawaguchi, 2014).

Malnourishment, as a result of dental disease or otherwise, should be addressed prior to anaesthesia. A patient with an American Society of Anaesthesiologists (ASA) physical status of III or higher may require further stabilisation prior to elective procedures being performed (Milella and Gurney, 2016).

Whenever possible, examination of the extent of dental disease should take place in order to anticipate not just the degree of oral pain the patient may experience but to also estimate the length of time the procedure may take to complete. In addition, the ability to open the mouth should be verified. Older patients with temporomandibular joint disorders may have only a limited range of jaw motion which could make later intubation difficult. Techniques for achieving intubation in these scenarios should be considered prior to anaesthetic commencement.


Appropriate agents should be chosen dependent on the patient’s underlying health status. Opioid analgesia should form the basis of pre-anaesthetic medication of patients scheduled for dental surgery and depending on the health status of the patient may be combined with either acepromazine or an alpha-2-agoinist to improve sedation. Drugs that commonly cause salivation, nausea and vomiting may be undesirable (Milella and Gurney, 2016).

In addition to its sedative effects, the inhibition of dopamine activity in the chemoreceptor trigger zone as seen following acepromazine administration produces a mild anti-emetic effect which may be of use in reducing nausea and vomiting associated with some opioids (Dugdale, 2010).

Alpha-2-agonists such as medetomidine and dexmedetomidine have the added benefit of analgesia as well as being effective sedative agents, although their use may be precluded in some, including older patients, with pre-existing conditions.

When used at clinical doses, opioids and benzodiazepines are considered to have minimal impact on the cardiovascular system and can be administered individually or in combination for premedication (Murrell, 2007). However, the use of this combination may not be appropriate in healthy individuals due its mild sedative effect, and potential for excitation or aggression through loss of learned inhibitory behaviours. Diazepam is often cited as an appropriate agent for the premedication of geriatric patients, but clinicians should exercise caution as marked respiratory depression may result in this group even at moderate doses (i.e. 0.2mg/kg IV) (Rigotti and Brearley, 2016)

Although anti-cholinergic agents may be used to reduce salivation, their use is rare nowadays in pre-anaesthetic medication.


Induction agent choice will depend on clinician preference. Alfaxalone is an injectable anaesthetic agent with minimal impact on the cardiovascular system when used at clinical doses in both healthy and high risk (ASA III-V) patients and so may be considered an appropriate option in geriatric patients (Muir et al. 2008; Muir et al. 2009; Psatha et al. 2011).

It is prudent to allow enough time for the patient to reach an adequate anaesthetic depth before starting oral examination. This is to prevent regurgitation should the gag reflex be stimulated whilst the patient is too lightly anaesthetised (Milella and Gurney, 2016).

Airway Management and Anaesthetic Maintenance

Endotracheal (ET) intubation is considered mandatory for all dental/oral procedures (Milella and Gurney, 2016). Not only does this allow for the effective delivery of an appropriate volatile agent (i.e. isoflurane or sevoflurane) in order to maintain anaesthesia following induction, but in dental procedures the presence of a cuffed ET tube will prevent dental debris and fluid from entering the airway. Supraglottic airway devices (e.g. V-GEL®) are unlikely to form an adequate seal and so are not recommended for use in dental procedures.

Maintenance of anaesthesia using intravenous anaesthetic agents (e.g. alfaxalone or propofol) are considered sub-optimal to the volatile agents for dental/oral surgery as inadequate suppression of the gag-reflex may occur and the recovery period could be prolonged (Milella and Gurney, 2016).

Care should be taken with patient positioning and the pharynx should always be packed to provide an extra barrier from dental debris and fluid reaching more caudal structures. This specifically designed packing should also be routinely checked for full saturation, ensure it is not so tightly inserted that it may reduce lingual blood supply and secured to the ET tube so that is not accidently left in place following the dental procedure.

As in all instances, care should be taken if cuffed ET tubes are used in cats as over inflation can cause tracheal rupture (Hardle et al. 1999).

A degree of tracheal and pharyngeal trauma may also occur during the procedure due to repeated ET tube motion as the patient is repositioned or head moved to achieve better access for dental therapy. This should be limited as much as possible as post-extubation airway spasm and obstruction can occur secondary pharyngeal trauma and fluid accumulation.


In the case of geriatric anaesthesia, if it is anticipated that the length of the procedure will extend beyond 20-30 minutes it is recommended that the most comprehensive monitoring possible should take place (Rigotti and Brearley, 2016). Geriatric patients have limited organ reserve and as a result the cause of any alteration to a given physiological variable should be identified and corrected immediately (Rigotti and Brearley, 2016). 

Fluid Therapy

Intravenous fluid therapy, at a rate appropriate for the patient’s clinical state, should be administered throughout the procedure to ensure maintenance of circulating blood volume and arterial blood pressure.

The 2013 AAHA/AAFP fluid therapy guidelines report that as a rule of thumb in healthy patients a balanced electrolyte crystalloid solution may be given at a starting rate of 3ml/kg/hr in cats and 5ml/kg/hr in dogs (Davis et al. 2013). As geriatrics are less able to conserve fluid through resorption through the kidney it is vital that both fluid type and rate of administration is based on patient assessment and in line with individualised requirements in this patient population (Rigotti and Brearley, 2016).


Pharyngeal packs should be removed, and the pharynx confirmed to be clear of any remaining debris before the ET tube cuff is deflated and the patient is extubated. The early recovery period, as with any patient recovering form anaesthesia, should be focussed on analgesia, airway protection and patency, fluid therapy and temperature management (Milella and Gurney, 2016). Geriatric patients should be monitored closely until they have fully recovered their airway protective reflexes and are fully conscious.

Once fully recovered, pain assessment should be performed regularly, and supplementary analgesia provided as required. Attention should also be paid to the patient’s ongoing fluid intake and nutrition.



This technique provides an alveolar reserve of oxygen should problems arise during endotracheal intubation. Recent literature suggests that 3 minutes of 100% oxygen delivered to a patient via close-fitting face mask increases time to patient desaturation in the presence of apnoea (Ambros et al. 2008). Flow-by techniques may be used if the face mask method is considered impractical (e.g. in stressed patients) although attention must be paid to the distance of the equipment delivering the oxygen from the patient’s nares (less than 2.5cm away is considered most effective).

Given certain age-related changes often seen in older patients (e.g. reduced vital capacity, increased lung fibrosis, reduced respiratory muscle function), these cases will benefit from 5 minutes of face mask pre-oxygenation if tolerated.

Locoregional Anaesthesia

The use of locoregional anaesthetic techniques will allow for lower doses of anaesthetic agents to be used and should be considered as a complementary adjunct to general anaesthesia for dental procedures (i.e. balanced anaesthesia). This is of relevance in all patients undergoing dental procedures but of particular importance in geriatric patients where the side effects of anaesthetic drugs may be more pronounced and where their presenting clinical condition may have resulted in lower doses of other anaesthetic/analgesic agents being initially administered.  

Duration of procedure

Dental procedures are often, and sometimes unexpectedly, prolonged. For this reason, specific focus should be made towards the patients positioning, analgesic plan and temperature management. As mentioned in the paragraph above, a combination of locoregional blocks and opioid analgesia allows for effective, and often prolonged, analgesia whilst reducing the dose requirement of other anaesthetic agents. Infusions of appropriate analgesic drugs may also be used in order to optimise perioperative analgesia.


Heat loss starts as soon as the patient’s premedication has been administered and temperature management is considered an essential part of any patient’s anaesthetic. However, special attention should be paid to geriatric patients as reduced central thermoregulatory mechanisms and altered body compositions limits their ability to maintain body temperature as effectively as younger . In addition, heat loss is often increased in dental/oral procedures as the mouth is kept open, and fluid frequently poured onto mucous membranes for the purpose of irrigation and to cool dental equipment. Measures should be taken to reduce heat loss in every instance and active warming methods adopted should a patient’s temperature drop below normal the reference range.

Post-anaesthetic blindness in cats

In cats, blood supply to the brain, retina and inner ear is provided by the maxillary artery. At one stage this artery courses along the caudal aspect of the mandible and can become compressed when the mouth is opened, restricting blood flow through the vessel (Stiles et al. 2012). Cerebral ischaemia and blindness can result and as such, the use of mouth gags to achieve maximal opening of the mouth is not recommended in this species. Precautions that can be taken include minimising the duration of any procedures that require wide opening of the mouth and using alternative methods to reduce the force with which the jaw is held open (Jollife, 2016; Milella and Gurney, 2016).

Post-anaesthetic deafness

This complication has been reported following both dental procedures and ear-cleaning in cats and dogs. Of the 62 reported cases, 42 occurred secondary to dental procedures. The induced deafness was permanent, no other associated factors were identified, and it was geriatric patients that were mostly affected (Stevens-Sparks and Strain, 2010).


The specific anaesthetic considerations for patients undergoing dental procedures are both vast and varied. The above article discusses some of these considerations as well as highlighting those that are of importance in geriatric patients.

Article by
Dr. Dan Cripwell
BSc (Hons) BVSc CertAVP (EM) PgCert (VPS) MRCVS

National Veterinary Technical Advisor UK
RCVS Recognised Advanced Veterinary Practitioner

Originally published: Thursday, 15th August 2019


Ambros, B., Carrozzo, M.V. and Jones, T. 2018. Desaturation times between dogs preoxygenated via face mask or flow-by technique before induction of anesthesia. Veterinary Anaesthesia and Analgesia. 45(4): 452-458.

Davies, M. and Kawaguchi, S., 2014. Pregeneral anaesthetic blood screening of dogs and cats attending a UK practice. Veterinary Record. 174(20): 506-506.

Davis, H., Jensen, T., Johnson, A., Knowles, P., Meyer, R., Rucinsky, R. and Shafford, H. 2013. 2013 AAHA/AAFP fluid therapy guidelines for dogs and cats. Journal of the american animal hospital association. 49(3): 149-159.

Dugdale, A (2010). Veterinary Anaesthesia: Principles to Practice. John Wiley & Sons.

Hardie, E.M., Spodnick, G.J., Gilson, S.D., Benson, J.A. and Hawkins, E.C. 1999. Tracheal rupture in cats: 16 cases (1983-1998). Journal of the American Veterinary Medical Association. 214(4): 508-512.

Joliffe, C. 2016. Ophthalmic surgery. In: BSAVA Manual of Canine and Feline Anaesthesia and Analgesia (Third Edition). John Wiley & Sons.

Joubert, K.E. 2007. Pre-anaesthetic screening of geriatric dogs. Journal of the South African Veterinary Association. 78(1): 31-35.

Milella, L., Gurney M. 2016. Pain management II: local and regional anaesthetic techniques. In: BSAVA Manual of Canine and Feline Anaesthesia and Analgesia (Third Edition). John Wiley & Sons.

Muir, W., Lerche, P., Wiese, A., Nelson, L., Pasloske, K. and Whittem, T. 2008. Cardiorespiratory and anesthetic effects of clinical and supraclinical doses of alfaxalone in dogs. Veterinary Anaesthesia and Analgesia. 35(6): 451-462.

Muir, W., Lerche, P., Wiese, A., Nelson, L., Pasloske, K. and Whittem, T. 2009. The cardiorespiratory and anesthetic effects of clinical and supraclinical doses of alfaxalone in cats. Veterinary Anaesthesia And analgesia. 36(1): 42-54.

Murrell, J. 2007. Choice of premedicants in cats and dogs. In Practice. 29(2): 100-106.

Psatha, E., Alibhai, H.I., Jimenez-Lozano, A., Armitage-Chan, E. and Brodbelt, D.C. 2011. Clinical efficacy and cardiorespiratory effects of alfaxalone, or diazepam/fentanyl for induction of anaesthesia in dogs that are a poor anaesthetic risk. Veterinary Anaesthesia and Analgesia. 38(1): 24-36.

Rigotti, C. F. and Brearley, J. C. 2016. Anaesthesia for paediatric and geriatric patients. In: BSAVA Manual of Canine and Feline Anaesthesia and Analgesia. BSAVA Library. 418-427.

Robertson, S.A., Gogolski, S.M., Pascoe, P., Shafford, H.L., Sager, J. and Griffenhagen, G.M., 2018. AAFP feline anesthesia guidelines. Journal of feline medicine and surgery. 20(7): 602-634.

Stevens‐Sparks, C.K. and Strain, G.M. 2010. Post‐anesthesia deafness in dogs and cats following dental and ear cleaning procedures. Veterinary Anaesthesia and Analgesia. 37(4): 347-351.

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Caesarean Section Survival Guide. Part 1: Physiology & Pre-anaesthetic Considerations.

In the first instalment of this 2-part review Karen examines the physiological changes that occur during pregnancy and how those adjustments can affect the selection of anaesthetic protocols for the increasingly common Caesarean section.

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No leeway for the spay: A comparison between methadone and buprenorphine for perioperative analgesia in dogs undergoing ovariohysterectomy.

This recent paper compares post-operative pain scores and requirement for rescue analgesia following premedication with methadone or buprenorphine, in combination with acepromazine or medetomidine, in 80 bitches undergoing ovariohysterectomy.

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Cardiac arrest - the human factor

Cardiac arrest in dogs and cats is, thankfully, relatively rare. However, when it does happen it can have devastating consequences for the animal, owner and the veterinary team. This study examined the common causalities leading up to a cardiac arrest with the aim of changing protocols to improve outcomes.

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Are you Using Safety Checklists in your Practice?

In this article, Carl focuses on the benefits of introducing a safety checklist in practice to reduce patient morbidity, mortality and to improve communication between members of the veterinary team. The article contains links to the AVA safety checklist as well as a link to a customisable list that you can adapt to your practice needs. 

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The Big Chill - Temperature Management in Sedated and Anaesthetised Patients

The effects of hypothermia are very far reaching throughout the peri-anaesthetic process. In this article, James takes us through the interesting mechanisms of body cooling and warming, the clinical relevance of hypothermia and what we can do to prevent it.

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Keeping the Finger on the Pulse -  Nuances in CV Monitoring

All patients are exposed to the risks associated with general anaesthesia. Continuously monitoring anaesthetised patients maximises patients safety and wellbeing. In this article, Dan takes us through the common monitoring techniques that provide information about the cardiovascular status of your patient. 

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Effect of Maropitant on Isoflurane Requirements & Postoperative Nausea & Vomiting

Despite being widely recognized in humans, postoperative nausea and vomiting (PONV), and the role of maropitant in reducing inhalational anaesthetic requirements have been poorly documented in dogs. This recent study evaluates PONV and isoflurane requirements after maropitant administration during routine ovariectomy in bitches.

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New! Alfaxan® Multidose Now Available

We are happy to announce we have enhanced our anaesthesia and analgesia portfolio with the introduction of Alfaxan®Multidose for dogs, cats and pet rabbits.

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Sevoflurane requirement in dogs premedicated with medetomidine and butorphanol

Little information is available about the effect that different doses of medetomidine and butorphanol may have when using sevoflurane for maintenance of anaesthesia in dogs. This recent study evaluates heart rate and median sevoflurane concentration required at different dose rates.

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Capnography II - What happened to the elephants? A summary of abnormal traces

In this second article of the capnography series, James provides a guide to a few of the most common traces that you will encounter during surgery. Scroll to the end of the article to download a printable capnography cheatsheet. 

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Pain, what a Pain! (Part 2) – Practical Tips On How To Perform Dental Nerve Blocks In Companion Animal Practice

In this second article of the Pain, what a Pain! series, Dan takes us through the LRA techniques associated with dental and oral surgery. In this article, you will find practical tips and pictures on common dental nerve blocks as well as safety concerns to consider.

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​Peri-anaesthetic mortality and nonfatal gastrointestinal complications in pet rabbits

This recent retrospective study looks at the cases of 185 pet rabbits admitted for sedation or general anaesthetic and evaluates the incidence and risk factors contributing to peri-anaesthetic mortality and gastrointestinal complications.

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Pain, what a Pain! How Locoregional Anaesthesia can Improve the Outcome and Welfare of Veterinary Patients (Part 1)

In this first article out of a series of two, Dan takes us through an introduction and practical tips for appropriate local anaesthesia delivery. Find out why these anaesthesia techniques, that are well recognised in human medicine, have seen an increase in popularity in veterinary medicine over the recent years

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Perspectives on Premeds – Opioids

Perspectives on Premeds is a series of articles touching on different pharmacological, physiological and clinical aspects of pre-anaesthetic medication. This second article aims to provide a refresher on opioids.

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Effects of Dexmedetomidine with Different Opioid Combinations in Dogs

Read the highlights of a recently published research paper that evaluates cardiorespiratory, sedative and antinociceptive effects of dexmedetomidine alone and in combination with morphine, methadone, meperidine, butorphanol, nalbuphine and tramadol. 

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Preoxygenation Study Highlights

This study evaluates the effectiveness of two methods of preoxygenation in healthy yet sedated dogs and the impact of these methods on time taken to reach a predetermined haemoglobin desaturation point (haemoglobin saturation (SpO2) of 90%) during an experimentally induced period of apnoea.

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Capnography – Not Just a Load of Hot Air

Capnography is the measurement of inhaled and exhaled carbon dioxide (CO2) concentration. The graphical illustration of CO2 within respired gases versus times is known as the capnogram.

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Perspectives on Premeds – Alpha-2 Agonists

Perspectives on Premeds is a series of articles touching on different pharmacological, physiological and clinical aspects of pre-anaesthetic medication. This first article aims to provide a refresher on α2 agonists.

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Alfaxan - now licensed for use in pet rabbits

Jurox Animal Health is delighted to announce that Alfaxan is now licensed for cats, dogs and pet rabbits. This is an exciting advance and could change the way rabbits are anaesthetised in the U.K.

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